The goal for the proposed dissertation study is to explore how the Massachusetts Acute Care Hospital industry is undertaking structural and process improvements to organize and deliver health care services that address quality, access to care, and effectiveness for racial and ethnic minority consumer groups. The research questions seek to examine: 1) At what structural levels are acute hospitals more (or least) likely to adapt quality improvement efforts to develop competence in delivering care to racial and ethnic minority groups? 2) In what manner do acute hospitals describe implementing service processes to improve access and delivery effectiveness for these minority groups?; and 3) who are the cultural brokers contributing to organizational response, what are their roles in advancing policies and practice that leads to developing culturally competent systems of care, and what do they identify as important to fostering system change in service practices? This exploratory study will use hospital quality measures data obtained from the Massachusetts Medicaid program and ethnographic interviews with cultural brokers in a sub-set of acute care hospitals. Quantitative analysis will be used to identify industry trends and patterns in structural and service process adaptations. Scale reliability and validity of the cultural competence assessment scale used for the study will be performed. Qualitative cross-case analysis from interviews in hospitals reporting more vs. lesser adaptations will explore the factors that might explain differences in system response to improve quality care and services for racial and ethnic consumer groups. The proposed study has both theoretical and practical policy relevance as it will provide a framework for health care organizations, regulatory bodies, and purchasers of care to identify, measure, and monitor quality indicators that lead to improved performance and access to quality care for racial and ethnic consumer groups.